HS Key Terms

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actual diagnosis

A human response to a health condition or life process that is happening at the present time.

assessment

The systematic and ongoing collection of comprehensive data relevant to a patient’s health or to the situation or ambience influencing the patient’s health.

audit

A record or chart review.

baseline data

Data taken at the time of the first encounter with the patient.

defining characteristics

The manifestations, or signs and symptoms, of a diagnosis.

dependent interventions

Nursing interventions that are ordered by a physician or carried out under a physician’s supervision for the treatment of a medical diagnosis.

diagnosis

A clinical judgment about the client’s response to actual or potential health conditions or needs.

emergency nursing assessment

The data collection process that occurs in a life-threatening situation.

evaluation

The process of determining both the client’s progress toward the attainment of expected outcomes and the effectiveness of nursing care.

focused health data assessment

The performance of selected portions of the patient history and examination process whenever specific conditions warrant this action.

implementation

The process of carrying out the plan of care, which may include any or all of the following activities: providing, monitoring, delegating, coordinating, teaching, and counseling.

independent interventions

Nursing interventions that are initiated by the nurse and that address nursing diagnoses.

Maslow’s hierarchy of needs

A tool for prioritizing nursing diagnoses; according to this hierarchy, a patient’s basic physical needs must be met before his or her safety needs, then social needs, then esteem needs, then self-actualization needs.

nursing

The protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.

nursing process

A process for the delivery of nursing care that involves the following steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.

objective data

Signs or observations made directly by the nurse that are capable of being verified by another person.

outcome evaluation

An examination of quality indicators such as number of patient falls, number of new pressure ulcers formed, number of postoperative wound infections, and number of tube-fed patients developing aspiration pneumonia.

policies

Written instructions designed to address a commonly occurring problem in an institutionally approved manner.

possible diagnosis

A diagnosis that is being investigated but has not yet been confirmed.

primary data

Data that the nurse derives directly from interaction with the patient.

The appropriateness of the care given and whether policies and procedures were followed to maximize patient safety, minimize medication error, minimize infectious contamination, and ensure that patients and families feel welcome.

protocols

Institutionally approved, preprinted instructions governing interventions or actions to be taken in the care of groups of patients with particular problems.

quality improvement (QI)

Methods that focus on diagnosing system problems and suggesting interventions to address those problems.

risk diagnosis

A diagnosis that is likely to occur in a vulnerable person.

risk factors

Those variables that increase a patient’s vulnerability to developing an actual nursing diagnosis.

secondary data

Data derived from sources other than direct interaction with the patient.

standing orders

Institutionally and departmentally approved instructions granting the nurse the authority to act in the absence of a physician.

state nurse practice act

A legal act that regulates the practice of nursing within each state.

structure

The setting or the environment in which care is given.

subjective data

Data that relies on a conscious patient providing a narrative statement or report.

syndrome

A cluster of diagnoses that are linked to a patient’s condition.

terminal evaluation

Evaluation of patient outcomes prior to discharge of the patient from the hospital or prior to a case being closed in a community setting.

time-lapsed nursing assessment

A repeated assessment obtained to compare data collected at one or more points in time with baseline data.

wellness diagnosis

A human response to achieve an even greater level of wellness.

activities of daily living (ADL)

The basic self-care tasks of living, including feeding and eating, bathing and hygiene, dressing and grooming, toileting and continence, and moving and transferring.

adaptive model

A model of health, wellness, and illness that views health as adaptation to the physical and social world in which a person lives and disease as maladaptation to this world.

agent

The substance that causes a disease.

alarm reaction

The flight or fight response, which is the first portion of the response-based stress model and is mediated by the sympathetic nervous system.

auscultation

Listening to sounds emitted from the patient’s heart, arteries, respiratory tract, or intestinal tract, typically through use of a stethoscope.

biofeedback

A process by which the body learns to bring autonomic nervous system responses under its control.

clinical model

A model of health, wellness, and illness that narrowly defines health as the absence of disease.

concrete imagery

A form of imagery that involves the creation of realistic images that are physically and physiologically correct.

countershock phase

The second phase of the alarm reaction, during which the physiologic changes that occurred during the shock phase reverse themselves.

disease

A specific pathologic state with defined signs and symptoms.

end-state imagery

A form of imagery that involves picturing the final state of a process or situation.

environment

The surroundings in which both a disease-causing agent and an affected host exist.

Eudemonistic model

A model of health, wellness, and illness that focuses on health as well-being, self-fulfillment, and self-actualization.

exhaustion phase

The final phase of the response-based stress model, which occurs if the resistance phase is unsuccessful; during this phase, the body either rests and recovers, or death occurs.

general adaptation syndrome (GAS)

The bodily response to stress that involves the adrenal and lymphatic structures and the gastrointestinal tract.

guided imagery

Imagery that is led by a therapist in person or on tape.

health behaviors

Actions taken to promote health, protect health, or prevent illness and disease.

health beliefs

A person’s health-related convictions.

health status

A person’s health state or condition at one particular point in time.

Healthy People 2010

The nation’s disease-prevention and health-promotion agenda, which is coordinated by the United States Department of Health and Human Services.

host

The person, animal, or insect that is affected by a disease.

hypnosis

A method of altering consciousness by focusing attention on one thought, thereby distracting consciousness from other thoughts.

illness

An unhealthy state or condition of the mind or body in which physical, social, emotional, intellectual, or spiritual functioning is compromised.

imagery

A stress-reducing technique in which the patient produces mental images.

inspection

The systematic, primarily visual examination of a body part or structure.

instrumental activities of daily living (IADL)

Tasks involving the basic tools or instruments of daily life needed to live independently; these include the ability to use a telephone, prepare meals, launder clothes, clean house, take medicine, and handle finances.

local adaptation syndrome (LAS)

A bodily response to stress that involves only one organ acting alone.

meditation

An altered state of consciousness in which the mind is focused in passive attention and quiet, resulting in an experience of transcendence.

Touching the patient with the pads of the fingers to detect vibrations or discriminating changes in texture or consistency.

percussion

Using the fingers to tap the patient’s body lightly but sharply.

primary prevention

Preventing illness and disease before it occurs.

process imagery

A form of imagery in which a procedure or process is mentally rehearsed in a calm and relaxed atmosphere.

progressive relaxation

A stress-reducing technique in which the patient progressively tenses and relaxes each muscle group, concentrating on the differences between feelings of tension and feelings of relaxation.

resistance phase

The phase of the response-based stress model during which the body attempts to cope with the stressor.

response-based stress model

The model of stress and adaptation in which stress is considered to be a response.

role performance model

A model of health, wellness, and illness that views health in functional terms; here, if a person can function, he or she is healthy.

secondary prevention

Detecting and treating diseases and health problems in their earliest stages.

shock phase

The first phase of the alarm reaction, during which epinephrine and cortisone are released and the body prepares itself for flight or fight.

sickness

The opposite of wellness; a state of not being well.

stimulus-based stress model

The model of stress and adaptation in which stress is defined as a stimulus.

stress

The forces or stimuli that impinge upon an individual; also, an individual’s response to these forces.

stressors

Another name for the forces or stimuli that cause stress.

symbolic imagery

A form of imagery that involves picturing an abstract situation in order to symbolically represent a real-life situation.

tertiary prevention

Restoring, maintaining, and maximizing health and optimizing functioning in the later stages of illness or disease.

transaction-based model of stress

The model of stress and adaptation in which a person’s response to an environmental stimulus is either blocked or facilitated by a variety of factors, such as the sensitivity of the person to stress and the person’s vulnerability at any one point in time.

wellness

The process of making healthy lifestyle choices daily to maximize one’s health potential.

yoga

A system of belief and practices aimed at the union of the individual self with the universal self.

adaptive equipment

Equipment that is intended to assist a person in dealing with limitation and risk by modifying the environment.

elbow restraint

A type of restraint that is used in the care of infants or small children to prevent flexing an arm to scratch or touch skin on the face or head, primarily during surgery.

environment

The sum of the physical and psychological factors that influence life and survival.

hazard

A condition or phenomenon that increases the risk of injury.

Hendrich II Fall Risk Model

A fall risk assessment that targets older adults at risk of falling within an acute care environment.

injury

A sustained hurt, damage, or loss.

internal risk factors

Internal variables that increase a person’s vulnerability to injury.

limb restraint

A type of restraint that is placed on a patient’s ankle or wrist to restrict movement in a limb during IV infusions.

mitt/hand restraint

A type of restraint that is placed on a patient’s hand to prevent the patient from scratching and injuring himself or herself.

mummy restraint

A blanket wrapped in a special way to enclose a child’s body to prevent movement during a procedure.

Omnibus Budget Reconciliation Act (OBRA)

A federal law passed in 1987 that, among other things, states that nursing home residents have the right to be free from physical or chemical restraints that are not required to treat specific medical symptoms.

para-aminobenzoic acid (PABA)

A substance frequently included in sunscreens that increases their effectiveness.

RACE

An acronym that can help nurses remember the appropriate steps for dealing with a fire: (1) rescue and remove clients who are in immediate danger, (2) activate the fire alarm, (3) confine the fire,and (4) extinguish the fire.

risk of injury

The probability or chance of injury due to factors internal and external to the individual.

safe environment

An environment in which the kind and number of hazards are reduced and accidents are prevented.

safety

The freedom from risk of injury.

safety strap/belt

A type of restraint that is placed around a client’s waist and secured in the back of a wheelchair or stretcher to protect the client from falling while he or she is being moved.

sunscreen protection factor (SPF)

A number that indicates how long a person who applies a particular sunscreen may remain in the sun before burning.

ultraviolet A (UVA)

Longer waves of ultraviolet light that are responsible primarily for photosensitivity, photoallergic, or phototoxic reactions.

ultraviolet B (UVB)

Shorter waves of ultraviolet light that are responsible primarily for burning, tanning, and skin cancer.

vest restraint

A type of restraint that consists of a sleeveless jacket with tails; the tails are tied to the bed frame under the mattress or to the back of a chair.

active dressings

Dressings that create a moist environment.

airborne transmission

Infection transmission by means of droplet nuclei or by dust particles.

alginate dressings

Moisture-maintaining dressings that interact with a wound to create a moist environment, stimulate growth releasing factors and cellular activity, and provide autolytic debridement.

antibody-mediatedresponse

Another name for humoral or circulating immunity, which resides in the B lymphocytes; these cells produce proteins called antibodies that defend the body against specific pathogens.

autoclave

A device that sterilizes objects by supplying steam under pressure.

barrier precautions

A method for limiting the spread of infectious organisms that involves the use of barrier methods such as gloves, gowns, resuscitation masks, and goggles.

cell-mediated defense

Another name for cellular immunity, which resides in the T cells; these cells attack and kill invading organisms.

cleaning

The removal of all foreign material from objects by cleansing, which inhibits the growth of organisms.

cohorting

A method for limiting the spread of infectious organisms in which infected patients and the staff members who care for them are assigned to a particular unit or set of rooms.

contact precautions

A method for limiting the spread of infectious organisms that involves placing infected patients in a private room and observing gown and glove precautions.

convalescence stage

The time period between the disappearance of the acute signs and symptoms of a disease and full recovery.

critical items

Items that enter the patient’s vascular system and/or tissue during the delivery of nursing care.

Davol drainage system

A system that consists of a drainage tube, a bottle with a port, a rubber bulb, and a balloon.

decolonization

Attempts to decrease bacterial populations in infected persons.

dehiscence

The partial or complete rupture of a sutured wound.

destructive phase

The second stage in the process of wound healing, in which macrophages continue to clean the wound and stimulate fibroblast formation and collagen synthesis; this stage lasts from two to five days.

direct transmission

A mode of infection transmission that involves touching, biting, kissing, sexual intercourse, or droplet transmission within three feet.

disinfecting

The process in which chemical solutions are used to rid inanimate objects and surfaces of pathogenic organisms other than spores.

environmental measures

Actions taken to disinfect all surfaces and equipment in an environment to decrease reservoirs of bacteria.

eschar

A scab-like crust or covering made from the remnants of dead skin tissue.

evisceration

The protrusion of abdominal organs through a dehisced wound.

external hemorrhage

The type of hemorrhage characterized by loss of fresh, bright red blood.

films

Adhesive or non-adhesive dressings that provide transparency so the wound site may be easily monitored.

fistula

An abnormal track or passage from one epithelial surface to another.

foam dressings

Absorbent, non-occlusive dressings used for wound beds that are highly exudative.

friction

A force acting parallel to the skin’s surface.

hemorrhage

An abnormal loss of blood from a wound caused by a dislodged clot, a slipped ligature, or a blood vessel tear or erosion.

Hemovac drainage system

A round, flat drainage bag with springs; this bag is fed by tubing that is connected to the surgical wound being drained.

hydrocolloids

Acid-based dressings that tend to discourage growth of bacteria.

hydrofiber dressings

Dressings composed of absorbent cellulose fibers shaped into ropes or sheets; these fibers provide for autolysis and are highly effective at absorbing excess exudate.

hydrogels

Dressings with limited absorbency that are best used for dry to mildly exudative wounds.

illness stage

The stage during which the specific signs and symptoms of a disease are present.

immunoglobulin

Another name for an antibody, which is a type of plasma protein that defends the body against specific pathogens.

incubation period

The time interval between the invasion of a pathogen into the body and the first signs or symptoms of infection.

indirect transmission

A mode of infection transmission that involves either a vehicle or a vector.

infection

The invasion of a wound by pathogenic organisms at the time of injury, during surgery, or postoperatively.

infectious agent

The microorganism that causes an infection; the first link in the chain of infection.

inflammatory phase

The first stage in the process of wound healing, in which hemostasis occurs, platelets accumulate at the wound, exudate forms, and white blood cells begin to clean the area; this stage lasts for about three days.

interactive dressings

Dressings that create a moist environment and interact with the wound they cover to stimulate cell activity and growth.

internal hemorrhage

The type of hemorrhage characterized by the formation of a hematoma, which is a collection of blood beneath the skin.

Jackson-Pratt drainage system

A system that consists of an elongated, oval shaped bulb that is connected to a drain from a surgical site.

maturation phase

The fourth and final stage in the process of wound healing, which is characterized by increasing strength of wound closure over a period of several months and perhaps up to a year.

medical asepsis

Biological safety techniques used during daily routine care to prevent infection or control its spread.

mode of transmission

The way in which an infectious agent travels between a reservoir and a portal of entry in a new host; the fourth link in the chain of infection.

moisture balance dressings

Occlusive dressings that produce moist wound environments, cause little adherence to the wound, possess long wear time, promote the healing of epithelium, and decrease pain.

noncritical items

Items that contact the patient’s intact skin but not his or her mucosal membranes during the delivery of nursing care.

nonspecific defenses

The body’s anatomic and physiologic barriers to infection, as well as its nonspecific inflammatory response.

passive dressings

Dressings that serve a protective function only.

Penrose drain

A commonly used drain that consists of soft, pliable, rubber, open tubing with a gauze wick in its center.

portal of entry

The gate through which an infectious agent enters the body; the fifth link in the chain of infection.

portal of exit

An infectious agent’s exit gate from its reservoir; the third link in the chain of infection.

primary intention

The type of wound healing in which the sides of the wound are approximated and held in place.

prodromal stage

The time interval between the onset of nonspecific signs and symptoms of infection and the onset of more disease-specific signs and symptoms.

proliferative phase

The third stage in the process of wound healing, which is characterized by beginning wound closure and increasing strength of closure between opposing sides of the wound; this stage lasts from three to twenty-four days.

reservoir

Any person, animal, arthropod, plant, soil, or substance where an infectious agent lives and multiplies and on which it depends for survival; the second link in the chain of infection.

secondary intention

The type of wound healing in which the sides of the wound are not approximated but are allowed to close by filling with scar tissue.

semicritical items

Items that contact any of the patient’s mucous membranes or skin that is not intact during the delivery of nursing care.

shearing force

A force resulting from a combination of friction and pressure.

specific defenses

The body’s immune defenses against infection, including antibody-mediated responses and cell-mediated responses.

sterilizing

The process of destroying all microorganisms, including spores.

surgical asepsis

The techniques used to establish and maintain a field free of all organisms, including spores.

surgical field

A sterile environment in which surgery and other procedures take place.

Any person at risk for infection because his or her defenses are weakened or compromised; the sixth link in the chain of infection.

topical negative pressure system

A vacuum or negative pressure assisted drainage system designed to promote wound healing and facilitate wound closure.

Yates drain

A drain that consists of a series of open capillary tubes and is made of polyethylene.

acetylation

A drug biotransformation process that occurs in the liver.

active transport

The process in which energy is expended in order to move a molecule across a cell membrane.

adverse effects

Undesirable drug side effects that can range from tolerable or manageable to life threatening.

carcinogenic reactions

Drug-induced changes in DNA, which may lead to the development of cancer.

catheter

A device that can be used to deliver drugs directly to the superior vena cava or to the right atrium of the heart.

central venous line

A device that can be used to deliver drugs directly to the superior

vena cava or to the right atrium of the heart.

chain reaction

The situation in which a drug causes a cascade of effects that each relate to the effects take took place before them.

chemical name

A name that provides information about the chemical composition of a drug; these names are not used clinically but are of interest to research pharmacists and chemists.

clearance

The rate of drug removal from the body.

cumulative effects

Effects that occur when the serum plasma level of a drug rises or when the amount ingested exceeds that excreted.

curative drug

A drug that has healing as its therapeutic effect.

dependence

A condition characterized by withdrawal symptoms upon discontinuation of a drug.

diagnostic drug

A drug that has certain effects that will rule in or rule out a specific

disease.

diffusion

The process by which certain dissolved substances passively move back and forth across a cell membrane.

drug absorption

The entry of a drug into body cells by means of diffusion, active transport, or pinocytosis.

drug biotransformation

The process by which a drug is broken down and used by the body.

drug distribution

The process by which a drug is delivered throughout the body.

drug excretion

The process by which a drug and/or its waste products are eliminated from the body.

drug metabolism

Another name for drug biotransformation.

first pass effect

A term that refers to the absorption of a drug through the intestinal tract and the drug’s entry into the portal circulation before entering the systemic circulation; this allows the liver to detoxify the substance before its wide distribution throughout the body.

generic name

The nonproprietary name of a drug.

half-life (t½)

The length of time necessary for the concentration of a drug in a specific area of the body to decrease by 50 percent.

Harrison Narcotic Act

A federal law passed in 1914 that classified narcotics and established regulations governing their importation, manufacture, sale, and use.

iatrogenic effect

An illness that is induced in a client by a drug given for a treatment or therapeutic purpose.

idiosyncratic reactions

Unexpected, abnormal reactions to a drug.

intradermal agents

Drugs that are administered between the layers of the skin.

intramuscular

Term describing the route of administration by which a drug is injected directly into a muscle.

intravenous

Term describing the route of administration by which a drug is delivered directly into the vascular system without needing to pass through a capillary wall.

narcotics

Marijuana, opium, cocaine, and their derivatives, along with combined analgesics.

nebulizer

A device that delivers a fine mist or spray; it may be used to deliver medication and moisture to the lungs.

official name

The name of a drug as published in the U.S. Pharmacopeia and National Formulary; this name may be identical to the drug’s generic name.

onset of drug action

The interval of time between the administration of a drug and the time at which the drug reaches a concentration that produces a response.

palliative drug

A drug that has the relief or alleviation of disease signs and symptoms as its therapeutic effect.

pharmacokinetics

The combined processes of drug absorption, distribution, biotransformation, and excretion.

pinocytosis

The process by which a hollowed-out portion of a cell’s membrane encloses a substance and then carries it into the cell.

plateau/steadystate principle

The fact that, when a drug is given at fixed intervals, it takes four or five half-lives for its plasma concentration to reach a steady state or a plateau level.

prodrug

A drug that, upon biotransformation in the liver, produces active metabolites.

prophylactic agent

A drug that has the prevention of infection and disease as its therapeutic effect.

ratio

A relationship in degree or number between two things.

Rotahaler

An inhaler that accepts capsules containing cromolyn or albuterol in powdered form; the capsule is punctured, and the inhaler then releases a powdered mist to be inhaled.

side effects

Actions or effects of a drug that are not specifically intended.

Spinhaler

An inhaler that accepts capsules containing cromolyn or albuterol in powdered form; the capsule is punctured, and the inhaler then releases a powdered mist to be inhaled.

subcutaneous

Term describing the route of administration by which a small amount of a drug is injected into the tissue just below the surface of the skin.

supportive therapy

The promotion and maintenance of healing and/or normal physiologic processes.

teratogenicreactions

Drug reactions that result in abnormal fetal development.

therapeutic index (TI)

A ratio of the dose of a drug that was lethal in 50 percent of the animals tested to the dose of the drug that was effective in 50 percent of the animals tested.

time to peak

The interval of time between the administration of a drug and the time at which the drug reaches its highest effective concentration.

titration

Adjusting a dose to achieve a desired effect.

tolerance

A condition of decreased responsiveness to an agent after repeated exposure.

toxic effects

Effects secondary to an elevated plasma concentration of a drug.

trade name

The name that a drug company has assigned to a product.

trough level

The plasma concentration of a drug prior to the next dose.

affective domain

The portion of learning that involves emotional responsiveness; it addresses feelings, emotions, attitude, and appreciation.

attending

A behavior that facilitates effective communication; it involves facing the other person squarely, adopting an open posture, leaning forward, maintaining eye contact, creating a relaxed affect, and responding appropriately.

attentive listening

A process that takes into consideration what is being said verbally as well as the content, the feeling, and the nonverbal cues the sender is communicating.

brevity

Using as few words as possible to communicate a message.

channel

The medium used to communicate a message.

clarifying

A method of eliciting clearer or more specific information.

clarity

Preciseness in speech and enunciation.

cognitive domain

The portion of learning that involves thinking; it addresses the intellectual skills of knowing, comprehending, and applying knowledge.

common advice

Advice that is based not on a scientific rationale but on one’s unprofessional opinion or preference at the moment.

decoder

Another name for the receiver of a message.

encoder

Another name for the sender of a message.

feedback

Another name for the response to a message.

focusing

A technique that helps a person recognize an underlying feeling or state his or her main concerns.

introductory phase

The second phase of the therapeutic helping relationship, in which the relationship is opened, the problem is clarified, and the structure and form of contact is established.

learning

A change in human disposition or capability that persists and that cannot be solely accounted for by growth.

message

One of the elements of the communication process; the content of what is communicated verbally and/or nonverbally.

open-ended statements

Questions and prompts that allow and/or encourage a person to tell his or her story or express his or her own feelings.

paraphrasing

Restating the point that a person is expressing.

preinteraction phase

The first phase of the therapeutic helping relationship, during which the nurse has basic demographic and illness data on the client but has not yet met the client.

psychomotor domain

The portion of learning that involves motor skills.

reality interpretation

A technique that clarifies events for an individual by helping him or her realize and understand what is really occurring in the environment.

receiver

The person who listens, observes, attends, and interprets a message.

reflecting

Redirecting statements or comments back to a person.

response

A receiver’s verbal and/or nonverbal reaction to a message, which allows the sender to determine whether the message was accepted, rejected, understood, or misunderstood.

sender

The person who initiates a message; one of the elements of the communication process.

stereotyping

Applying generalizations to an entire population of people.

stimulus

One of the elements of the communication process; the reason for communicating or the motivation behind a communication.

teaching

A system of activities intended to produce learning.

termination phase

The fourth and final phase of the therapeutic helping relationship, which ideally concludes with the client having a positive attitude and feeling capable of functioning independently in the future.

therapeutic helping relationship

A relationship in which the nurse and patient collaborate to promote the patient’s health and solve problems.

working phase

The third phase of the therapeutic helping relationship, in which thoughts and feelings are explored and understood, and the nurse facilitates the client’s decision making and supports appropriate action.